[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomID.pdf] of only this state's summary also available]
Residential or Assisted Living Facilities: Idaho Administrative Rules IDAPA 16, Title 03, Chapter 22
General Approach and Recent Developments
Regulations were revised in March 2006. The title and scope of the regulations describes the philosophy which is “to provide choice, dignity and independence to residents while maintaining a safe, humane, and home-like living arrangement for individuals needing assistance with daily activities and personal care. These rules set standards for providing services that maintain a safe and healthy environment.” The state covers services in licensed facilities under the Medicaid state plan and the HCBS waiver. Revisions to the criminal background check requirements are being developed. All facilities must install sprinkler systems by 2010 if they serve individuals who cannot evacuate safely. Life safety code requirements for small facilities were strengthened in 2006.
Adult Foster Care
Certified family homes are regulated separately and provide care to one or two adults, who are unable to reside on their own and require help with ADLs, protection and security, and need encouragement toward independence. The Department of Health and Welfare sets standards for certified family homes. Rules are available at: http://adm.idaho.gov/adminrules/rules/idapa16/0319.pdf.
|http://www.healthandwelfare.idaho.gov/site/3630/default.aspx||Provider, survey check lists, application, training materials|
|https://chu.dhw.idaho.gov/||Criminal history site|
|Residential care or assisted living||278||6,819||266||6,193||253||5,815|
Residential or assisted living facility means a facility or residence, however named, operated on either a profit or non-profit basis for the purpose of providing necessary supervision, personal assistance, meals, and lodging to three or more adults not related to the owner. In this chapter, RCFs or ALFs are referred to as “facilities.” Distinct segments of a facility may be licensed separately, provided each segment functions independently and meets all applicable rules.
Facilities licensed after July 1, 1992, must not have more than two residents in each bedroom and provide 100 square feet of floor space per single-bed room and 80 square feet per resident in multi-bed rooms. There must be at least one toilet for every six persons, residents, or employees, and at least one tub or shower for every eight persons, residents, or employees. New construction must meet the requirements of the ADA Accessibility Guidelines and the Life Safety Code. Existing facilities must remove as many barriers as possible without creating an undue burden on the facility.
The revised statute and regulations dropped licensing by the LOC provided. Residents may not be admitted or retained if they require on-going skilled nursing or care that is not within the legally licensed authority of the facility. Residents who require on-going highly technical skilled nursing services may not be served. Residents may not be served who require gastronomy tube, arterial-venal shunts or supra-pubic catheters inserted within the previous 21 days; receive continuous total parenteral nutrition or IV therapy; require physical restraints, including bed rails, comatose, except for a resident who has been assessed by a physician or authorized provider who has determined that death is likely to occur within 14-30 days; rely on a mechanically supported breathing system, except for residents who use continuous positive airway pressure; has a tracheotomy who is unable to care for the tracheotomy independently; are fed by a syringe; have open, draining wounds for which the drainage cannot be contained; have a Stage III or IV pressure ulcer; or with any type of pressure ulcer or open wound that is not improving bi-weekly; have methiccillin-resistant staphylococcus aureus in an active stage (infective stage).
The facility must assure a licensed nurse is available to meet the needs of any resident who has needs requiring a nurse. Residents cannot be admitted or retained who have physical, emotional, or social needs that are not compatible with the other residents in the facility or that are violent or a danger to himself or others. Residents requiring assistance in ambulation must reside on the first story unless the facility complies with specified sections of the rules.
Facilities may request a waiver to serve people if they show good cause for granting the waiver, describe the extenuating circumstances and any compensating factors such as additional floor space or staffing that have a bearing on the waiver.
Facilities are required to ask if the resident has an advance directive, and they may assist residents in developing advance directives.
Nursing Home Admission Policy
The assessment areas are divided into critical, high, and medium indicators. To qualify for nursing home admission, applicants must have one or more critical indicators; two or more high indicators; one high and two medium indicators; or four or more medium indicators. The indicators are presented below.
|Criteria for Determining Nursing Home Need|
|Indicators||Level of Need|
|Critical -- 12 points for each indicator||Total assistance preparing meals
Total assistance in toileting
Total or extensive assistance with medications which require decision making prior to taking or assessment of efficacy after taking
|High - 6 points for each indicator||Extensive assistance preparing or eating meals
Total or extensive assistance with routine medications
Total, extensive, or moderate assistance with transferring
Total or extensive assistance with mobility
Total or extensive assistance with personal hygiene
Total assistance with supervision for a section of the uniform assessment instrument
|Medium -- 3 points for each indicator||Moderate assistance with personal hygiene, preparing or eating meals, mobility, medications, toileting
Total, extensive, or moderate assistance with dressing
Total, extensive, or moderate assistance with bathing
Frequent or continual supervision in one or more of the following: orientation, memory, judgment, wandering, disruptive/socially inappropriate behavior, assaultive/destructive behavior, self preservation, or danger to self or others
Services are included in a negotiated service agreement and may include room; board; assistance with ADLs; supervision; assistance and monitoring of medications; laundering of linens owned by the facility; coordination of outside services; arrangement for routine, urgent, and emergency medical and dental services; emergency interventions; housekeeping services; maintenance; utilities; access to basic television in common areas; maintenance of self-help skills; recreational activities; and transportation to trips to social functions.
A uniform assessment and a negotiated service agreement must be used with residents. The agreement covers the results from the uniform assessment; the level of support in ADLs; health services; the level of assistance for medications; the frequency of needed services; the scope of needed assistance; habilitation needs and the program being used if applicable; training needs; identification of specific behavioral symptoms; situations that trigger the behavior symptoms and the specific interventions for each behavioral symptom; physician or authorized provider's signed and dated orders; admission records; community support systems; the resident's desires; transfer plans; discharge plans; and the identification of individual services being provided by other providers and who is providing the service.
The menu must be adjusted for age, sex, and activity as approved by a registered dietitian. Physicians’ or authorized provider orders must be received for therapeutic or modified diets. The facility must have a menu planned or approved, signed and dated by a registered dietitian prior to being served to the resident. The planned menu must meet nutritional standards. Menus will provide a sufficient variety of foods in adequate amounts at each meal. Food selections must include foods that are served in the community, in season, as well as residents' preferences, food habits, and physical abilities. The menus must be prepared in advance and available to residents on request. Snacks must be available and offered to residents between meals and at bedtime. The facility must have a therapeutic diet menu planned or approved, signed and dated by a registered dietitian prior to being served to a resident.
The admission agreements must be signed prior to or on the date of admission. The agreement must include: services provided; staffing patterns and qualifications; whether the facility carries professional liability insurance; the facility’s and resident’s roles and responsibilities for assistance with medication administration; fee descriptions; whether the facility is responsible for personal funds; handling of a partial month’s refund; conditions for emergency transfers; permission to transfer pertinent information; resident’s responsibilities; and other items. The agreement may be integrated with the negotiated service agreement provided all requirements for both are met.
An agreement may not be terminated except under the following conditions: a 30 day written notice; the resident’s physical or mental condition deteriorates to a level where the facility can no longer provide care; non-payment; for the protection of the resident or other residents from harm; and other conditions.
Provisions for Serving People with Dementia
A facility admitting and retaining residents with diagnosis of dementia, mental illness, developmental disability, or traumatic brain injury must train staff to meet the specialized needs of these residents. The means and methods of training are at the facility’s discretion. The training should address the following areas: an overview of dementia; symptoms and behaviors of people with memory impairment; communication with people with memory impairment; resident's adjustment to the new living environment; behavior management; ADLs; and stress reduction for facility personnel and resident.
Other training is required for facilities that serve individuals with mental illness, developmental disabilities or traumatic brain injuries.
Only licensed nurses may administer medications for residents. Aides who have passed required training may assist residents with medications. The requirements for administration and assistance with self-administration of medications by unlicensed assistive personnel are specified by the Board of Nursing. Facilities must have a policy describing the process the nurse will use to delegate assistance with medication and how it will be documented.
Personal care in assisted living was added as a state plan service in 2000. Services under a Medicaid HCBS waiver using the waiver application definition and including medication administration and assistance with personal finances was implemented in 1999. Elders, people with disabilities, and people with mental retardation, traumatic brain injuries, or developmental disabilities are eligible. Coverage was phased in across the state. The HCBS aged and disabled waiver program serves 2,231 residents living in residential or ALFs. Individuals are eligible for the waiver using the 300% SSI eligibility criteria.
State plan services are available to individuals who require no more than 16 hours of personal care services per week. Individuals must meet state income limits for financial eligibility. Providers are paid based on four levels of need which are determined by the number of hours of assistance needed. Payment rates range from $125.30 to $225.54 a month. The resident is responsible for paying for room and board. The state’s suggested limit is $542 per month; however the facility may charge the resident more. Family supplementation is allowed. Any money remaining after paying for room and board is retained as a PNA.
HCBS waiver payments are capped at the average per capita nursing home cost and individual payments are based on a care plan. The facility can set its rate for room and board however the state’s suggested rate is $542 per month for rent, utilities, and food. The individual SSI payment rate for individuals residing in residential facilities is $623. Any monies remaining after payment of room is board is retained as the PNA.
State supplementation to the SSI program has been phased out. In 2002, the Legislature directed the transition of individuals who were receiving the supplemental grant to the Medicaid state plan. Supplementation for the room and board payment is allowed in all categories. A uniform assessment instrument is used to determine the unmet ADL needs for all applicants. The unmet needs are converted to a payment that is available to the beneficiary regardless of where he or she lives: in assisted living or their own home or apartment. The process was developed to eliminate differences in payment and service delivery depending on where a person lived.
Facilities must have written staffing policies and procedures based on the numbers of residents, resident needs, and configuration of the facility. A LPN must visit the facility at least once every 90 days or when there is a change in the resident’s condition.
Small facilities 15 beds or less must have at least one or more qualified and trained staff, immediately available, in the facility during resident sleeping hours. If any resident has been assessed as having night needs or is incapable of calling for assistance staff must be up and awake. For facilities licensed for 16 beds or more, qualified and trained staff must be up and awake and immediately available, in the facility during resident sleeping hours.
Facilities must employ and schedule sufficient personnel to provide care, during all hours, required in each resident's Negotiated Service Agreement, to assure residents' health, safety, comfort, and supervision, and to assure the interior and exterior of the facility is maintained in a safe and clean manner; and provide for at least one direct care staff with certification in first aid and CPR in the facility at all times.
Administrators must have a valid residential care administrator’s license. Personnel must be given an orientation to the facility and participate in a continuing training program developed by the facility.
Staff. New staff must receive a minimum of 16 hours of job-related orientation training before they are allowed to provide unsupervised personal assistance to residents. Orientation training must include: the philosophy of residential care or assisted living and how it guides care giving; resident rights; cultural awareness; providing assistance with ADLs and IADLs; how to respond to emergencies; documentation associated with resident care needs and the provision of care to meet those needs; identifying and reporting changes in residents' health and mental condition or both; documenting and reporting adverse outcomes (such as resident falls, elopement, lost items); advance directives and do not resuscitate (DNR) orders; relevant policies and procedures; and the role of the Negotiated Service Agreement. All staff employed by the facility, including housekeeping personnel, or contract personnel, or both, who may come into contact with potentially infectious material, must be trained in infection control procedures for universal precautions. Each employee must receive a minimum of eight hours of job-related continuing training per year.
Before staff can begin assisting residents with medications, the staff must have successfully completed a Board of Nursing approved medication assistance course. This training is not included as part of the minimum of 16 hours of orientation training or minimum of eight hours of continuing training requirement per year.
Effective October 1, 2007, all applicants for licensure must submit a criminal history clearance as described in IDHW rules Title 05, Chapter 05. The rules include finger printing, FBI, National Criminal History Background Check System, state registries and Medicaid sanctions lists. Individuals pay $48 for the cost of the check.
With the exception of the initial surveys for licensure, all inspections and investigations shall be made unannounced and without prior notice. Surveys are conducted within 90 days from initial licensure followed by a survey within 15 months. Facilities receiving no core issue deficiencies during both the initial and the subsequent survey will then enter the three year survey cycle or once every 12 months, or more frequently at the discretion of the Licensing and Survey Agency for those facilities receiving core issue deficiencies during any survey. Surveys will be conducted until the facility attains two consecutive surveys, excluding follow-up surveys, without a core issue deficiency. Surveys are done at least every 36 months for those facilities with no core issue deficiencies for two or more consecutive surveys. Complaint investigation surveys are done based on the potential severity of the complaint. Inspections entail reviews of the quality of care and service delivery, resident records, and other items relating to the running of the facility. If deficiencies are found, then plans of correction are made and follow-up surveys are conducted to determine if corrections have been made. Complaints against the facility are investigated by the licensing agency. A complainant’s name or identifying characteristics may not be made public unless “the complainant consents in writing to the disclosure; the investigation results in a judicial proceeding and disclosure is ordered by the court; or the disclosure is essential to the investigation. The complainant shall be given the opportunity to withdraw the complaint before disclosure.”
Enforcement options include ban on admissions, ban on residents with certain diagnosis, civil monetary penalties, appointment of temporary management, suspension or revocation of the license, transfer of residents, issuing a provisional license and other remedies. Facilities operating without a license may be subject to six months in jail and fines up to $5,000.
In 2004, the Department changed the survey focus from a pure regulatory compliance survey process to a survey process that combined compliance oversight with technical assistance. The Department regularly partners with the industry to present focused training based on trends identified through the survey process. The survey process rewards well performing facilities in that they are placed on a three year survey cycle. Facilities that do not have a track record of high performance are surveyed annually until they can establish a high performing track record and earn their way on to a three year survey cycle. When significant issues are found during survey, a plan of correction is required from the facility and once the facility has remedied the problems, a follow-up survey is conducted.
$500 for a building evaluation.
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